Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

mental. Is the life stream working now? Then we're going to check. Um it is, um it's looking Okay. Awesome. Right? Right. Welcome, everyone. I'll just be doing the introduction today. Unfortunately, REVONTO president is has a prior commitment to come. So we send these apologies. Uh, so today we've got a great finals easy session lined up for you. So it'll be hematology part to the Thank you for joining Part one on today is gonna be a really great session by our very own trinity. Eso Please stay tuned. A quick shout out to our sponsors is starting off with the MPs medical protection services, the great organization, um, that provides support the medical students in cases off things like lawsuits and, um, our practice and things like that and even doctors as well. So please do John drawing the organization. It's a free membership, and you have a chance of winning weekly 183 lbs. Uh, if you join. Wait. Sorry to disturb you moving. I think there's, um we're using at the moment when you have the maximum one and your participants don't change it back to the mosque. Easy. The big one. Oh, is it? Okay? Okay. Okay. You tell people to join on metal with that? No. What's the life stream, right? Yeah. I'm wondering why yet have we pay for the one? Okay, when do you know? Do you know? Sure, we'll just ask people doing its two metal there. So if you please join the metal live women page been said, can you post the link to be on the page, please, on the on the Facebook page? And if any of your friends are joining, please do shot Lincoln. You are, um we are trying a new hybrid system, so we're using on some middle because we're hoping to do a transition. This is the first step. So please bear with us until we, you know, kind of work. They bugs out, then stuff, um, and apologies for any. Any inconvenience. So I just carry on? No. So we have em to you as well. Another great question is Well, I'm helping medical students and junior doctors with any any kind of legalities that concerned them and chart out to meddle great international organization that we're proud to be sponsored. By the way. Uh, it's a method of feedback from his wells. And they've been a great help for us and also anastomosis Well, making medical on healthcare professionals around the world. And then you have question it as well. A great question, bank. We all use it and, um, you absolutely only really useful. So please do join Quest, man requestion bank, um, and use the code are squeezy print 20 for a 20% discount. And also we have the squeezy community and with, and we'll just put in the Beatles of us. Well goes, well, anyone, any student to kind of ask questions, getting opportunities. And you also have pieces on benefits off what we'll be covering in our weekly sessions. So please do follow us and join our community on, But it's definitely gonna be helpful for you guys. So today's session we're trying Ah, new system. As I mentioned before, combination of human metal. You guys want to engage in the polling function? Please do join, Assume, do for that to happen. But you can also join in mental events pages Well on. Did we just put the Lincoln, um, you guys want to join him through that as well? Um, the pulling function is not unfortunately available there, but you can still do the lecture A Z Well, so make sure to keep your microphone and Cameron mute. Ask questions on the chat. Um, you can ask questions on the metal chat as well, if you have any, so don't worry about that. And please try to get in the pool. It is a Z can please be respectful. Please don't draw. Don't disrupt to speak on this section is currently being recorded. Okay, on the feet back for me will be sent on around half an hour to 25 minutes off. Starting the session destroyed that leg and we will upload the slides and the recording on two metal. Okay, so you want to fill in the feedback from can access the slides on the video and email us on our scale z at outlook or skip gym mode? Or call me family concerns or questions? Um, and make sure to remove those two emails from his family junk just to receive future newsletters regarding our future events. And please share. It's on your socials. Just get you get your friends interested as well. If they're. If you guys find our sessions useful and, uh, enjoying the good life for finals. So without further ado are pass it on to strangers. Has got a great presentation. Really, really mind provoking question. So I understand. Thank you very much. I like to apologize from our part regarding the 100 participants. It's something which we have not foreseen. But if you could please all tell your friends that the mental life has been posted on Facebook page the same content, hardly any leg. It's a partner. So see, uh, one of our very good partners. And please do join it through mental. That's the main message. Everything can be accessed there. You can Also in the chat, we have people lining the chats as well as, well, intervention. So yeah. Yeah, First of all, electric policy. I do have a good over here. Fever. Today is if you just suddenly see me sneezing. Please don't mind me. It's just a seasonal thing which I get another disclaim. I'd like to give you some of these questions. Might be a bit challenging, but the whole point is hematology is a very specialist field of medicine. As an F one. The main things you need to know. Is it recognizing the key red flag symptoms, understanding how to read an F. B. C. And I'm quite sure moving went to that very, very well. Today. I'll take you through a series of questions trying to ease your mind, trying to get the basic concepts out, as well as dying in different specialties and how they can link with hematological malignancies. That's what I'm gonna mainly be covering today. If you don't get the questions right, don't worry it all. This is a slightly step higher than your med student final levels. But if you get used to these questions, what you normally see in mustard and finals will be much, much easier. That being said, some of you might find the questions very easy, and by all means, that's very good. So we'll start with question number one. If I could have a boil up, please. Okay. Yeah. No, Uh huh, Yeah, I'll stop to pull it about 50 seconds, but I think so. Most of you have gone for a, which is chronic myeloid leukemia, So let's think this. Let's bring this question step by step. Can anyone tell me what the diagnosis of this patient is regarding their abdominal pathology. So what? Gastrointestinal hepatologic a problem? Does this patient have? Did anyone tell me? Yeah, he does have about, um ugly. Yes, Perfect. But Chiari brilliant. So he's presenting with the classic triad of abdominal pain about, um, ugly and ascites. Then the hepatomegaly with ascites highly suspicious off. But Carrie. But Chiari, as an issue beautifully explained, is a hepatic vein thrombosis. I'm very covered cause, or the perhaps the most covered keppra logical malignancy cause off. But Chiari is polycythemia rubra Vera. So the answer to this question is he actually in gastroenterology if you see a patient. But Chiari, you're thinking about polycythemia rubra Vera in hematology. If you see a patient presented with these signs, you know it's polycythemia rubra Vera. Okay. It's a condition. As its name suggests, you have excessive ear. It recites you have more red blood cells. Your blood become hyper risk us. So meaning very think. Take blood. Predis forces you to clocks virtuals try a Stasis of blood that figure the blood. The board's going to be standing by the left high for them. Less more. The floor. Let's faster the flow. There for the more risk of clots forming. And if we can get what Chiari you can present with strokes. Classically, the classic menstrual and final thing is that when you go out, come out of a hot bath and you feel itchy. That's when you start thinking about polycythemia rubra Vera. So for this question, very important to think if you see a patient you had a hematological malignancies went off on holiday. Mr Few, uh, clinic appointments. So probably didn't have his regular really sections. Hypercoagulable hyper viscous has thrown a lot of the hepatic vein. So, as I have previously mentioned, it's ah, proliferation of the RBC's hyperviscous blood. 90% of the time it's associated the jack to mutation. So many of these conditions you find out jak two mutations. But 90% of polycythemia rubra of your patients have this mutation they present with this stroke like symptoms. But characteristically flocks there hypercoagulable itching after the world but is a classic my student final type statement on investigations. You do a full blood count. Simple things. First, you'll see a raised red blood cell count, but to diagnose it. But the gold standard way to diagnose It is if if your bone marrow biopsy and you find a hyper sal you tomorrow with multiple richer sites. A blood filled will also show loads of red blood cells. Visual indicator. Point you to the direction of Polycythemia Riviera Treatment wise. Mainstay treatment. Regular. Very sections. Two Conditions should come to your mind for the treatment off, which is regular Venus sections. Penitentiary Hemochromatosis and polycythemia Rubra. Vera. Simple enough logic. They have lots of red blood cells. Let me take out some of the regular basis if I take out some red blood cells. Were taking out some of the blood introduces the risk. Awesome they're reducing the signs are the chances off that's being thrown. Hydroxyurea is a mild form of chemotherapy, which could be used at most of these patients. Require aspirin prophylaxis. Prevent the clot. Simple, essential trouble cytosis. As the name suggests, it's basically what do you have to really platelets? So preparation of mega car your sites, which resulted the production of excessive number of platelets. What do platelets doing? Normal physiology. They help us clock they from that first plot. The soft clock little It's essential for that. So in this case, What will happen is you become hypercoagulable again. 50% of the time. These patients have a jak two mutation so less than that scene in polycythemia rubra vera but still quite covered. Classic man student find a final symptom would be burning sensation in the hands, but all similar to a polycythemia rubra. You can find them with clocks and strokes, but there is also a possibility but less confidence in polycythemia rubra vera. So it's basically related to physiology to have excessive number of platelets. Hypercoagulable. This burning sensation of the heart is a classic finals question diaper intro and that brought from what, Once again, you do a full blood count. You see that the platelets are elevated gold. Standard way to diagnose is borderline a biopsy, which was sure that Medicare is that proliferation treatment. For this removing the blood doesn't have as much. So you do hydroxyurea to try and reduce the number of cells or reduce the proliferation of the counter sites and aspirin prophylaxis for the trump bite. Very important, we're going to question number two because if someone is launched the pool okay, Yeah, No, I'll stop it at 60 seconds perfect. So the answer you run for is a So it's a lot less for move to this question together. Shortness of breath, fatigue, dizziness. You should start thinking about anemia on examination. This conjunctival parlor. Okay, that supports your diagnosis. Now, from the history you know, the symptoms of anemia on examination, the Conjunctival parlor is increasing your suspicion that this patient is anemic. A large masses fell in the left upper quarter of the abdomen. Okay, so now I think that this patient has plenty of wiggly left upper quadrant large last more often than not would be clean. The question says a hematological malignancies suspected and a bone marrow biopsy's attempted, however, is unsuccessful. What is the most likely diagnosis now? I do appreciate This is a very tough question. But the key point I was going for here is the fact that this is something. Notice my low fibrosis. So the cells you typically see in myelofibrosis is noticed ear drop by color sites. So they literally look like a deer drop. And it's classic on a blood filled. But I'd like to explain Why is it mild fibrosis? Massive splenomegaly Which number one? This patient is anyway. But the biggest few in this question is the fact that on interruption or an attempted bone marrow biopsy, it was a dry tap. It was unsuccessful. What does this mean? This means that it's not a high percentage. Tomorrow there's something wrong because generally the bone marrow biopsy, you just pushing the needle. I'm just like a Syrian. You suck out some of the cells. It's like a bone marrow aspiration. You just suck on some of the cells and you have a decent sample of bored marrow. Just semi liquid are dried up within two aboard marrow biopsy, with the patient presenting with fatigue a large spleen on the left upper quadrant. You start taking it. Okay, this patient might have mild fibrosis. Why is this? This is because in a vial of fibrosis, much as the name suggests, there's college in D position and fibrosis. Fibrosis in the bone marrow, therefore hematopoiesis is worthless spleen. That's why you get the massive splenomegaly and you get a dry top on board. Micro aspiration. What you need to do for this patient. If you didn't take something known as a trigger, find biopsy and someone tell me What's the difference between a board marrow aspiration, our board marrow biopsy and it refined biopsy anyone on the chat? What's the difference between a board marrow aspiration? I don't. You're fine. Biopsy. Okay, No worries, I'll explain. It is an important concept to understand, because what happened in your fine biopsy already inject when you bush the needle. True, a small blood comes out, a plunger draws a vacuum. Should I space between the plunger, which creates a vacuum? And literally some of the bone marrow comes into the refined biopsy needle. So when you pull out, you have a small bit of bored matter, which comes out with it. Very, very useful for many women. Logical malignancies, but especially for mild fibrosis. Why it's not that easy to gain cells from a Goldman aspiration in violin fibrosis, they're fibrotic. They're stuck. They're they're tough. They don't want to come out to a small needle, but you're fine through you get a sample of the of the board marrow, and once you see the sample under microscopy, you see the fibrotic changes. You know it's mild fibrosis, very, very important. So that refined biopsy you're actually getting a sample We're taking out a small part of the bone marrow off the bone marrow, whereas in a board member biopsy also known as a bone marrow aspiration, you're introducing a needle and sucking out some of what's in the bone marrow. So that will only help if the border is high percent cellular and you could easily draw the cells. But in myelofibrosis is five product the position you can't draw them out. So that's why they refined biopsy. Because very important for patients with vial of fibrosis. Let's move on tomorrow. Fibrosis A problem Perforation. Platelet derived factors activates the fiberglass. So because of this excessive number of players drive factors activation. The fibroblasts, the fire roasted start deep depositing college and into the bone marrow. That's what's fibrosis. Basically of the boredom I wrote. You could get anemia. Get anyone. Tell me why you might get a loss of appetite in Myelofibrosis. Can anyone chat? Please tell me what, um, loss of appetite. Why? A patient with Smiler fibrosis might have a loss of appetite. Okay. No worries. I mentioned massive splenomegaly. What in the What's next to this plane next to the spleen is a stomach. You have massive splenomegaly. This tubal doesn't have that much room to expand. In which case ready taken food even a small amount Because it's bleeding, pushing on the stomach, you'll feel full. You'll feel satiated so, therefore invested. Spend a Mongolian patient of mine or fibrosis. They can get it early. Satiety. Full blood count. Ideally, do it. You're fine. Biopsy treatment is usually a board marrow transplant, so it could be autologous bone marrow transplant. If they have their board understood previously, or a very close relative, we should give a board where their bone marrow, with all the matching done in order for them to start making their cells again in their bone marrow, which will help reduce the size of this mean eventually. Some patients. We even require splenectomy later on. Once they're born, Marrow is functional, so my lower displaces is very rarely talked about condition. It's not a very common question exams, but still can come up so that I'm gonna go through it. No, it's a pre leukemia. It's It's a new plastic disorder, so it's this place here. Basically, the cells relive the bone marrow are changing. They're becoming this plastic, and it's a pre leukemia in which about 30 to 40% may progress on to acute myeloid leukemia. That's an important condition if you do diagnosis intubation. Usually it's elderly patients coming in with anemia bruising because of your platelets or dysfunctional platelets. Recurrent, in fact, infections you start thinking about. Okay, this might be a myelodysplastic disorder. This patient might have mild dysplasia, usually investigations wise, you do a full blood count. As always, aboard matter biopsy with shortness dysplastic changes within the cells. Treatment once again is born matter. Transplant. The main thing to know about minor displace here or the common question in medical student finals, which will be is that a patient has been diagnosed. Bipolar displace here. What is what which malignancies Yet risk off, and I'll give you a list of people logical malignancies. You will need to figure out which malignancies most at risk. Off on the malignancy is acute myeloid leukemia. So that's the max. Sure, and final Jake oh boy from the slide. So quick overview off the types of bone marrow transplants or tolerance is when the patient uses his old bone marrow, often when they're in remission or when they're No, but you can have their board markers are taken away and stored because that when did go back in or but when they have a flare off their condition, they can have their own borders are replaced in them. That's one option. Allergenic is from another person who's, you know, typically similar, usually close relatives that you know types are matched. The actually system is mashed. And then, based on that, you could do a board minor transplant of a little court transplant. Tell the further than that. But it's up to you if you're in the block. Many people from the older generation will not have that done, but that's something you could talk about. Another one more, more, more cardiology related. But does anyone know what a zero graft is? A xenograft from animals? Exactly, so it's from reading. Material or tissue for one species are transplanted it on the species rarely done in medicine. One example would be hard to valve, so you can use bovine valve. That's what one way where it's used. But the main ones for hematology arises autologous with the patient's old cells. When they're in remission, it's stored or allergenic from a close relative four causes of massive splenomegaly where I didn't by hematology placement. I was told by my hematologic, a kid's consultant, that this for have to be the tip of your fingers. You need to do these essential chronic while or leukemia mile of fibrosis kala-azar, which is basically a parasitic infections or is Restoril Licopin eyes is and malaria. These are the four common causes off massive splenomegaly. See ml vial of fibrosis. Color is art, and we'll area it is anything you take out of this lecture. This light should be one major part of it. The four major causes of massive splenomegaly, out of which I think in you case he ever on myelofibrosis. Maybe more common than the other two. The other two will be more caught prevalent in the developing countries. Moving onto questions. Three. Surgeon was us. How does my love my bro sis course splenomegaly. Yeah. So what happens in my life? Fibrosis? Is that because of this fibrotic be position within the bone marrow. Your body used to produce these blood cells elsewhere. So the spleen takes over the spleen, starts producing all these blood cells, and in doing so, it becomes it becomes larger in size, basically. So therefore, you get massive splenomegaly. And while if I wrote this Yeah, So remember, explain is one of the major organs involved with extra medullary multiple pieces because that's when he gets done. I'm sorry to interrupt you the election day. We have just expanded out some capacity. Now, please do let your friends or anyone know that you they can join now. All right. Sorry for the delay. Yeah, I think I think I'll call this full of with earlier 45 seconds. Perfect. So a really absolutely raped. Can anyone tell me what the condition is? What complication is this, or is this patient having? Do you realize the syndrome by effect? Another question and maybe slightly tougher white. And you realize this syndrome. Do you get a low calcium? Can anyone tell me why do you have a local ship in Cuba? Lysis syndrome finds with phosphate Brilliant. So the answer is actually in the question. The high phosphate causes the local ship. So for high phosphate will bind to calcium causing culture and precipitation of calcium Still impressive. It is. You can also happen. The calcium deposits being taken away from the serum. Therefore, and if you get a low calcium in patients with you were lysis syndrome. These ECD findings What electrolyte abnormalities indicated that Can anyone tell me? Yeah. So the CT shows flattened be waves and told tempted to the waves Absolutely. Hyperkalemic were brilliant. Quick, a quick one about hyperkalemic easy changes that hyperkalemic a are basically flatten. She get told that the T waves flattened be waves and then it becomes a Sinus little curve. So given the Z CD changes, I'm actually quite worried about this patient. On the immediate management of this patient would be to give culture gluconate. I need to stabilize this cardiac membrane and sure that he's not going to go into a life, need a written here before recommenced the other treatments. Very important. So whatever you're thinking about a question such Is this because a future practice really practical application off it. Always trying to think How would you manage this patient? So this patient absolutely has true humanizes drugs will have a high phosphate and low calcium, probably high, you realize well, but what we need to know is the fact that the media threat to this patient's life is the fact that he has hyperkalemic. I can go to reticulated cardiological afibrillation. So I need to give him cash of Lupron it stabilize the cardiac membrane, and I can look after the complications. Later on, he point to take over another question, then. Yeah. Okay. I'll call this one here. Absolutely. Right. So what is this patient have any ideas about the diagnosis? Neutropenic Sepsis. Brilliant. Absolutely. Nutribullet accepts is always you're the sepsis. Six. But the key point to remember is it Never wait for the blood cultures. The first thing to improve on the most important step in managing this patient is to give them IV antibiotics. Broad spectrum. You can't wait on that. You give them broad factor I'm talking about. Does this in? We just did your acid in it as a back down, which is recommended. So very, very broad spectrum antibiotics. A question for those out there who are in the UK UK guideline based. So if a patient Lexi has new tribute, accepts is but it's penicillin allergy action as a type one. Anaphylactic reaction. Do medicine. What other medication? What? The antibiotic that we give Uh huh. So I don't usually we give IV Tazicef marrow. Problem is absolutely option, but meropenem is very broad fracture. Um, it can be used absolutely gentamicin limited. Like under a meeting, like aside, gentamicin. Is it immediate, Like aside, but basically looking for very, very broad spectrum. Antibiotics differ from trust to trust in my trusted 50 go planning. But the whole point of trying to say is you want to give broad spectrum cover simple folks is, um not so much vancomycin. Not so much vancomycin and gentamicin can be used. You want to cover both gram negative gram positive, an aerobic and anaerobic. So go as broad spectrum antibody we can reprint. It was a good one. Usually left for last resort. Patients who do have medicine, allergies and my trust the gift. Take a planet. But the key point there is when you're at F one and you see the interpret accepts this before giving out the IV taxes in ensure drug allergies are awful. If that pain it's an allergic, you need to find out what other drug can be given. Still, think broad spectrum don't jump onto an amoxicillin that's too low and you want to give you ever everything possible because you don't know what but is affecting that. These people are very immunocompromised, Okay, So always do know the drug allergies. I think this is going to go through it during his oscal actors. Were drug allergies essential to us, so I'd be broad spectrum antibiotics. It is the briefly taking you through some of the oncological emergencies which you my face because okay, these are stuff which, as an F one, as a medical student, we should be able to recognize quite easily. Do you realize that syndrome high potassium high phosphate Lucash? Um, you got a hyper You receive your so high urea for you rate in the blood prevention. If you think of patient is at high risk for developing tumor lysis syndrome, for example, a patient who has a level 41 is undergoing high high dose chemotherapy or intensive chemotherapy. You think they're okay this patient's limb for more the cells might start bursting or license license. Basically, as the name suggests and he might go to Cuba like this, you can give them IV allopurinol or grasp irritates. They lower the your eight levels, reducing the risk of tumor lysis syndrome question I had out there. Just general medical. Really? Can someone tell me what the management of Hyperkalemia is? Okay, thanks. Yeah. Incident was dextrose. Sandy. Okay, is a good good, good. Good answer. The only thing that sound okay to take some time to work sound. Okay. Sorry. Sams. Okay, apart me is for hypokalemia sound. Okay, will be for replacement. Usually you start off with the Goshen. Lucrative if you're considered. If there you see changes or it's very high above six and 6.5, you want to give patients gosh, infergen and cardiac memory production. Basically, you can move on to insulin and dextrose. Nebulized albuterol is an option. So absolutely news of the correction on stairs That so into realize, is as a question outline. Always think about war. Water? That's right. Abnormality there is. And how can we do it? Hyper calcemia and malignancies. Another thing we just call when you see, we'll talk about some malignancies where it's very commonly seen. But in general, you can get something done. It's hyper telling me off The hyper calcemia off belligerency screen with seltzer are carcinoma Because of the lungs are common cause if it because it really is something this parathyroid hormone like peptide you got the classic groans would stone that bones. She got abdominal pain because stones in the bronchi get constipation. You get confusion, your boards will start. We could get free like I get bored pain. So usually if you see a patient a very high calcium level, Do you know what the easy change would be for that? Any idea if a patient comes in with a very high calcium level? Short Q t really, absolutely short duty usually is hyper something in this case, Hypercalcemia does cause short Q D syndrome. You don't jump to giving this phosphinates. So for generally, for patients who have happened, let me have a HEPA calcemia of malignancy. You can give them IV is alendronate or IV pamidronate. These are basically bisphosphonates, which will reduce osteoclastic activity. I'll repeat that they reduce osteoclastic activity with the bone reducing the couch, and results in which is going on reducing the amount of calcium going into circulation. But they take 3 to 4 days to work. You need to drop it down immediately. You give IV fluids. You're diluting the blood, reducing the amount of calcium. But more so. First step IV fluids. You start them on the IV bisphosphonate and which is lower down their calcium on you. Move on from there. Then slowly you can move with them off to the oral bisphosphonates, and eventually the calcium level is stable. You can stop them or you can keep them on the oral. Bisphosphonates really depends upon how they get on with the bisphosphonates and everything finally called compression. Very, very, very important to think about in any patient who has a past history of malignancy or is complaining off. Recent shooting pains down both their legs. Loss of anal sphincter control so basically called acquired a symptoms or in general, has neurological symptoms, history of malignancy or current malignancy. First things first. Think about MRI. Think about a cord compression. Well, let me ask you this way. Let's say a patient comes in, has all the symptoms of card compression. What is the first step in managing this patient? You're the F one and you see this patient and you know this is called compression. It's it's at night. What would you do first? I don't use it as a good on substituting it always to analgesia. But the main thing is that some dessert so many people would jump on SBE. So let's see the med student finally say, What is the next best management? Absolutely ridiculous. College is a very good answer, absolutely within an examination in the final final exam. If they give you a question, what's the next step? Best step in the management of this patient. Don't jump to MRI within 24 hours. Absolutely, they do it and I'm right with 24 hours. But if it's positive that this is called compression, give them high dose dexamethasone fest. By the time you do the MRI, they may have passed away. You need to give that a high dose dexamethasone. Get the knee, my dad, and then you do the MRI. Within 24 hours, you could feel the diagnosis, but if there is significant neurological deficits and you're sending this is got compression, next immediate step is to give them high dose dexamethasone. 16 mg usually is given. Stopped as we see you is basically superior vena cable obstruction. So that's when you have a large central Karasik must pressing on the superior vena cava. You got something experiment and sign, so any ostentatious raised their hands up. They get this facial flushing correctness distended veins that's known as I remember it and sign. It's basically because venous drainage from the head and neck is reduced as a result of compression. This computer vena cava I know most of us are usually relating this to more respiratory pathology, so lung cancer would be the first thing that comes to mind. We do know it's rare, but some live in four months with the drastic cavity can also compresses superior vena cava. So just keep it in mind and some some hematological malignancies. Massively, informers can also cause the symptoms, and once again, high dose dexamethasone straight away. You need to get rid of that, and even usually in SEC, we give 8 mg immediately stopped, and I've already answered this question. Why my TC distended veins in the head and neck and SBC you as a result, off reduced fetus drainage back to the heart from the head and neck the superior vena gave her. The name suggests drains the head and neck, so if you block it, you'll have distended veins. So we're going to perhaps something which is quite common. I've seen it loads of times in hematology and you must must must must know this neutropenic sepsis. So you suspect this is our any patient with risk of neutropenia any vision or any hematological malignancies. Let's see, they have colorectal cancer and one stage colorectal cancer and undergoing chemotherapy, they're at risk. Um Neutropenic, sepsis, even patients up tight on medication, for example. Carbs result. So be sure you're hypothyroid. We're giving a drug called carbazole which can cause them to be neutropenic suspect neutropenic sepsis. So the point is that any patient can be immunocompromised who is at risk of low white blood cells. Think Nutribullet, sepsis, usually diagnosing the neutrophil that below one. The immediate strip His immediate broad spectrum antibody is the order of the day. The main thing you need to do is you're not ready for blood cultures Do not wait for blood cultures. Do not wait for blood cultures. Stop them on the IV antibiotics. Once the body will just come back 3 to 4 days later, you could kill her and down. But you must not withhold antibiotic for them until blood cultures back. An important thing to notice. Some of these patients may not present with fever. Then we just have all the all the ah cognition. So maybe slightly confused. Maybe general a sergeant feeling on Well, even that immediately do a full blood count. Screen them. They may have neutropenic sepsis. So it's not always that these patients present with fever, especially. They're elderly. Many attack the door presented fever. You need to keep a look out for any change in their behavior. Any change in the regular functioning? Are they feeling well? Are they not feeling well? Ask them, Look at them and basically judgment upon that. Don't just say that a person is looking quite unwell, but doesn't have a fever. I can't be neutropenic sepsis. No, it can't be neutropenic sepsis. Screen them properly if they're at risk of neutropenia. First diagnosis to rule out is neutropenic sepsis. Well, we're going to question number five. Uh huh. Stop it at 60 seconds. So most of you gone for question for a once again, This is a very tough question. And don't worry, if you have not got discretion, is just something which you can see in really life as well as if it's a mean exam. You can get this exam. And if you do understand this question, you understand the condition very well as well, or at least how to diagnose the condition. So it's a 65 year old Caucasian man. So in a little early Caucasian man, interesting. Let's R G once again. You think you are okay. This patient may have some degree of anemia, Wife complains. It is no longer do your dishes or gardening, as he's so tired of that. Anemia, if it's causing the lethargy, is quite significant, and it's progressively getting worse. So it's nothing acute. It's an insidious under. The slow under is progressively getting worse. So when when you get a history like this on the thing about okay, so there's something we just continuously getting worse or something is progressing, basically, so this is not something acutely going wrong with this patient. It's not something sudden. It's something which is starting small, but now is taking a greater grip of the body. It's really, really increasing it. It's effects on the body, and that's when he starting. Okay, this may be something sinister his boss. Medical issues? Yes, several infections. That's really thinking. Okay, That means his white blood cells probably aren't working that well. There's something going wrong there. Yes, Bill Conjunctival once again confirmed your diagnosis off anemia or to a large extent in the bushes, you to work it out direction of anemia? No, every seizure is low. It's free. So he is an evening with a slightly raise every CV with the high ridiculous. I can't. So that's where the tricky it was really raised. Every CVD doesn't mean this patient necessarily has a B 12 or B nine deficiency. He may have with a high. Ridiculous I'd count on its own can push your MCV to be slightly higher. So given this presentation, what is the most likely diagnosis? What do we know from now? Is white cells are working Well, he's anemic. Is an elderly Caucasian man on? He has a high ridiculous side count high ridiculous. I count anemia. I'm thinking this patient has an IV elliptical Neemia, and tying all the conditions together. This patient probably has chronic lymphocytic leukemia. I have chronic lymphocytic leukemia. You generally see smear cells, so I'm quite sure many of you have in your mind The question. Then why is this chronic lymphocytic leukemia? The most important thing you need to know about CLL is the fact that it's the most covered Yuki me A in the western world among the elderly. Population number one, number two It's insidious onset. So this slow progression of symptoms often presented anemia, then moving on to recurrent infections. Okay, that moving on it's an important cause off a war or two immune hemolytic anemia. I'm glad you're moving. Mentioned that during his lectures. Well, so that's why this patient has this anemia with the high ridiculous. I'd kind cause he has a warm water in your hemolytic anemia. Yeah. Characteristic. You must remember this for your menstrual and final exams. Cll smear cells, CLL smear cells. Cielos were cells one Google. You'll see. You'll see how the cells look in livery literally. Looks like we take a lymphocyte and just monitor on a long plane. That's how it looks there also doing a smart cells because of that. But the key thing I wanted to remember from this question is the fact that in an elderly Caucasian male with an insidious onset of anemia. Recurrent infections. You're thinking about chronic lymphocytic leukemia, Or at least you want to rule it out. There's the same patient with this patient, then presents with the week later with severe night sweats, weight loss of multiple enlarged lymph nodes. What's happened to this patient to the exact same patient with a week later is common with this. The effect on stop the port. 40 seconds really in. Most of you have got this question, right, Richter transformation and anyone Tell me what that is. Anyone on the chat can tell me what rictus transformation is. Syringe, I think you might have frozen. Oh, yeah, I think Ah, I think the whole entire house electricity has just cut out the think there is ever around the house is going to scream, and we will be. Hopefully yesterday will be back in a few moments. But if you guys have any questions because even the chatting here on zoom or on metal be happy to answer them. Uh, well, he's back. I think our interconnection just dipped. Yeah, Everyone in the house. It is where it went off. Yeah. Interconnection suddenly be switched off. Sorry for that. guys. Any guys? Three months cream? Yeah, we consider for on his middle waking knish. Yeah, medicine perfect. I'll research from where I left them. So, uh, I was talking about a direct It's transformation. It's basically when a patient C L o the white blood cells are roaming around the lymphocytes a little roaming around. And once you enter, live a lymph node. The end of a proliferation on these patients that go into ah hi grain non Hodgkin's B cell lymphoma. I, usually on the special of severely, are really, really on. Well, I have massive be symptoms, sweating a lot and by sweating night sweats. No, not the usual ones we get on on the hot summers day, these people's bed sheets, pillow covers and drenched in sweat Bill. It really feel like they're swimming in a pool of their own strength. Multiple enlarged lymph nodes. You're highly suspicious. Richter. Transformation. Please. No, this question Very, very high yield. Common question to come up in progress tests. So please do it or this one the on my logic issue, Kenya's is understanding the stable. Honestly, this is the most important thing to understand. Live for derivatives. The Mile A derivatives. This is absolutely crucial to understand the fact that the label for progenitor cell you trust her a small liver site, which then further different, different shooting to decell. The B cell on the B cell gives rise to the plasma cells. Now let's look at how the malignancies fit into this. So a little is when there's a live in Fort Progenitor cell, which is a referred proliferating and undergoing the mutations and is malignant. Now that's a cute name from last Taking your Chemo. If it's a B cell, it's chronic lymphocytic leukemia. And finally, if it's the plasma cell, it's my lower. Always remember acute, meaning the younger cells are affected. The less differentiated, the less what your cells are affected. Chronic is a movement. Your cells are affected. We live for progenitor B cell for CLL on blast Myself of my low much know these three, and if you understand this one's, you'll never forget it. On my street and final, um, are CPX same nations. It comes in very, very happy handy. So now let's look at the cute lymphoblastic you came here. But the physiology is basically uncontrolled proliferation or malignant proliferation off the label for progenitor cells, you get no much your beer dealing for sites you get. Basically, your blood is filtered liver for blasts, which are immature cells. Yeah, it's much more common in Children, the most covered childhood malignancy. You could get recurrent infections, unexplained bruising or patikieye on a very important thing, which is rare for the other hematological malignancies. But it's very important there. All right, bye. Yeah, fact, it was logical science. And when they are having chemotherapy, they need intraarticular chemotherapy. So intrinsically is basically within the bureau space. You give it a doors of chemotherapy cause you do not want them to have made acidy should brain to the spine are stuff like that. So obviously it's very one of the CNS signs in acute lymphoblastic leukemia investigations once again. FBC blood FILLED board My ra biopsies Diagnostic treatment. Honestly, for these leukemias, you don't need to know much about treatment about for the menstrual and level final level. These are very advanced chemotherapeutic agents, which are tailored to the individual patient's requirements, their past medical history, how they're doing at that span of time, on in combination taking all those factors into consideration is when you go on for a treatment. I've listed one of the common ones years in the UK a regimen to induce remission. That means when the patient has active acute lymphoblastic leukemia, how can we suppress it? Get it out? And then there's another method to keep it in remission for about two years afterwards, the frequently check to ensure that they remain in remission. But do you mean in return? Nuestra Mission with history prednisolone Entre cycling, which is a type of, uh, chemotherapeutic agent and asparagine knees are used. Don't bother remembering. Cramming does very rarely, always, never tested. It's more just for your general knowledge. In your information. One important thing I would say, especially for lymph or months, is that where you suspect a limb for my innovation and you give them glucocorticoid or steroids introduces them because what the steroids do, start any with the immune system. So when you're doing that, your liver, your lymphoid or your liver for was, well, artificially be suppressed or reduced. And then if you go on and do it on ah excisional biopsy or something, you might get false negatives. The patient does have a lymphoma. But because of the steroid which is given to them, it was not found in investigations. That does happen in practice that can come up in exams. So what I want you guys to do at the back of your head is the fact that steroids can be using the treatment of these even logical malignancies, especially for lymphoma. When you're trying to investigate little form, I figured if you give a little cortical steroid before and you might not be able to find out the final diagnosis, just remember that would be fine. We're going to CLL. I spoke about CLL for a while, so I'll just waste through it. Are gonna proliferation of the B cells you get Hypo grab you, believe me, because the B cells obviously dysfunctional and it's the most common and arrested well, especially among feel elderly. So do keep that in mind at the back of your mind when in the question to give the fact that it's a 75 year old or 68 year old patient presented with the signs of anemia recurrent infections, you starting okay, It could be a cll type picture because it's the most common one which is diagnosed. So that's where the age and the background information of the patient comes in. Not only for progress tests Medical student final excuse, but also in general. When you're taking a history from a patient, when you're in F one in diagnosing a patient, it comes in very, very handy because of this reason. So you must know that CLL very commonly diagnosed with the elderly, so always try to rule it out once again. Insidious onset. Remember that I always feel full blood. Count on these patients. Very important, not filled with your smear or smart cells. Diagnosis against Once again born my biopsies. Classic treatment is actually interesting. Many patients don't ever require treatment. What 80% don't require treatment. You just keep monitoring that insurance is not progressing. It's risk. Stratify them, stage their condition. Obviously, if there are very high Steve, you are very high risk of the rectus transformation you want to treat. But most patients, because it's so slowly progressing and then I have nose quite later on in life, they'll ever require any treatment. That's the key point about CLL management. Many patients, because of its lower nature something similar to a basal cell carcinoma. Dermatology. It's slow progress, about 30% that don't require any intervention. You just watch and wait and see once. Once You feeling okay? No, it's progressing a mid to fast. You can jump into chemotherapy once against it. Came with a piece of mainstay on Rituximab is very important. Does anyone know what rituximab? How it works, Okay, especially looking after we're looking for a receptor which Inditex on D CD 20 and brilliant. Absolutely. It was an anti CD 20 city twenties found a wide range of immune cells. That's why you'll find it took some, uh, frequently used not only to to cure him a logical malignancies very common in the real world. For patients who want to go, you got granulomatosis and body angiitis. So basically what it does is it helps suppress the immune system by on injects and CD 20. City 20 is a receptor found on most immune cells. So you keep that in mind very important and a very common drug, and you'll definitely come across the during a clinical basement. Already gone through rigorous transformation. Only thing to do it about it is the be symptoms and someone Let's start the the symptoms for me. I think nitrate is one of them. Yeah, that's what's fever and another one last one. That's it. If you were the main thing. Often this is associated with weight loss. Absolutely. Yep, it's often associated with weight loss. We're taking a history or talking to someone who suggested that we have night sweats. Always try to quantify it. And sure, as I mentioned before, it's not the mild threat. It's actually, they're drenched. That's what you see. Plastic. We seen a non Hodgkin's lymphoma will find the patient's complaining of being drenched at night. That's classic off, uh, off the symptoms. The symptoms also seen an audience logical conditions. For example, TV causes be symptoms. HIV can cause night sweats as well and fevers. So when it's seeing a question and show you outdoors and then move onto the logical malignancies, coming to is the ending Now, really, let's move on to some more questions here. Launched a pole covered. I learned a boil here, so it's a very interesting question, actually, Um, and I completely understand why people who were you seeing, um, electrophoresis? It is often and very frequently used to diagnose multiple myeloma. I'm quite sure most if you got the diagnosis of multiple myeloma, given the high calcium and the ruler formation. But interestingly, I spoke to the hematologist about. This is, well, the best way to confirm that this patient does actually have multiple myeloma. The race most specific is to do a bone marrow biopsy and find that the plasma cells over 10%. So over 10% plasma cells on a bone marrow biopsy would indicate that this patient 100% has my Lola. So that's why all for what is the best investigation used. So if you want 100% dissipation has my Lupron can do a bone marrow biopsy? If the plasma cells are above 10% you're confirmed in your mind. There's nothing else going on. It is myeloma serum. Electrophoresis is urinary bands. Jones proteins, urine electrophoresis, all powerful blood family with the the real information are all indicated strongly mile over, but the best, best best method where you have absolutely almost left. Nothing to chance is a bone marrow biopsy and on the board marrow biopsy, over 10% of the cells should be plasma cells. So very important point you know it that something which they can catch you out and met student finals. So these are the type of questions which you think absolutely no difference is the answer, but they've actually being a bit sneaky and more more about is actually the best medicine to read the question and full and always think about what exactly are they asking for? And in most hematological malignancies, bone marrow biopsy will be the absolute answer. Correct answer. Because the pathology in most occasions is going on in the bone marrow. If you get an image of what's going on in the bone marrow, you'll be most show the bone marrow biopsy it is. Can anyone tell me wipe Asians with myeloma? Got a high calcium? Okay, any ideas why you get calcium? A high calcium hyper calcium? You in myeloma? Yep. Osteolytic activities are selected. A classic activity increases. That's absolutely right. Perfect. And that's because the paraproteins, which had released which trigger the osteoclast to start working, Why do you get real failure? Renal failure? Any idea why you get real failure? Real failures as a result of basically what happens in my room exactly. Like Cindy. Position. Perfect. So these paraproteins, which had deposited within the within the tubules, commit you bills. They destroy the kidney to real to get renal failure. Hyper calcium is really due to Australia. Australia. Lasting activity increased in myeloma. But you Do you are you, uh, okay, bone destruction of osteolytic to my lesions? I'm not exactly sure about that one. To be honest with you, you can get Plasmacytoid was in myeloma. But I'm not sure about bone destruction from Austin. Lytic Cuma is in general and malignancy. If you do have a nostril, a tick to where you could get a hypocalcemia. That's often what I do. Get a happy calcium and metastases metastases. But renal failure will usually, if you see if you think of it completely apart from him. A logical malignancies. Renal failure usually causes ah hypocalcemia because you can't convert vitamin D to its active fall. But in myeloma, the main reason why I got a hyper calcium is that osteolytic activity increase. So myeloma uncoupled control proliferation of the plasma cells. I showed you guys that liver for tree. It's the last one to the B cells. They differentiate too. Plus of ourselves on the plasma cells are the ones that produced or release the antibodies already. Immunoglobulins if you have a malignant proliferation of these plasma cells, you got a whole range of flowers myself secreting a lot of paraproteins years. Really? I g paraproteins some can be ideas. Remember, It's mostly I g r r a proteins dysfunctional. So that what does that? What does that mean? That you're an increased risk of infections. The trigger osteoclastic activity is you get hypocalcemia the light chain Deposition in the kidney tubules result in kidney failure on because you have this interest osteolytic activity. You can get bone pain, pathological fractures. So I know often we use the stem. Pathological fractures on many myeloma patients may actually present with pathological fractures and someone defined to me what basically is the pathological fracture. So why do you get infections? As I mentioned, because you have plasma cells which are producing dysfunctional immunoglobulins president producing enough stone track, they don't do their job. Therefore you're at increased risk of infections and yes, I did see is the most common. Absolutely. That's the perfect definition. So in general, the definition of pathological fracture should be a fracture caused by an injury, which should usually not cause a fracture. A simple Is that so? From a hyperintensity. Let's see, You're just falling from your own height and you've broken loads of bones. You're thinking okay. That should not generally happen if you're falling from standing. If you fall in from a lot of fair enough, you can break your bones were just fallen from standing on your own height. Have broken bones you're taking Okay, let me just rule out any proctologic a fractures there on many a time. The first presentation is my liver patients is let's see a hip fracture. They come in with a hip fracture. When you do the blood screening, you find that, Okay, these patients, we have something more sinister going on. Usually, the median age of diagnosis is 70 to 1 thing, and it's more in the elderly population. It's important to know that. Always remember crabby. So you get hyper calcemia renal failure anemia. You get bleeding, you know, low platelets, bone dysfunction. Our battle article fractures board been on increase infections. Someone tell me why these patients are anemic. Why do my normal patients become anemic. Does anyone have any idea little dysfunction leading to anemia? That will be more in the long term born murder filled up with dysfunctional anybody's? Absolutely So what happens? This plasma cells? Everything is building up, the more is becoming hypersensitive. And these high person in the plasma cells are taking up more space. So the other cells that megakaryocyte switch produce platelets. They're exercise that can be a little big made in the bone marrow cause the lack of space. And that's why these patients get this anemia, this increased risk of bleeding. It's basically because of a high percentage tomorrow. But the matter is not high personally because of all different types of cells. It's this one. Plasma cells start sticking there. So once I get investigations, why'd you do it? FBC Using these often progressed started medical food and final empty cues might have urinary bench Jones proteins. Bm to be absolutely sure that this is my little you do a bone marrow biopsy treatment Once again, you don't need to know in detail at all for the two different types. If a patient can have it on a log in stem cell transplant It means when they were in remission or before they got detected with my liver, they do have going my restored. You can give them something to in his board. So maybe on dexamethasone because Internet, Um, I'd alkylating agent, which is once a cleaning injuries. Once again, a chemotherapeutic agent and dexamethasone. We don't worry too much about the treatment. Honestly, with these ones, it's more about diagnosing, understanding why they're getting hypocalcemia for the treatment for hypocalcemia could be the e c g changes of hypocalcemia pathological fractures. Those are the more important parts of my little while and rather full rather than focusing on the treatment. Okay, so once again, restart like crab, be here. So hypercalcemia renal failure, anemia and infections. So if you see all four and a patient always rule out Mylar. Want to do a follow what screen? Basically, yeah, moving onto question number eight doing where you guys are. Almost done. Yeah, this is an easier question and the other ones, but one that does pop up every now and again in med student final exams. And this is something which, if you get into this, like do you have to go after get This is an easy work. Okay to do. Someone asked me What's the difference between myeloma on Angus? Ah, m Gus. And while Oh, uh, I'm raising I love to skip that one. I can think of off my head where it's not a pretty sure I think. And grasses Ah, it's a precursor lesion to my longer things of patient. The Precursor vision. Absolutely. Yeah. Nations can develop myeloma from, um, August. Yeah, if they can. Absolutely. It's Waldenstrom's microalbumin, which is I gm minor. That's separate, and M. Gus is it's unknown significance. You get this one, this fire proteinemia. It's not yet in my little more sleepy me if I'm wrong initial, I'm just thinking down those lines as far as I remember. I don't think the pathophysiology of multiple myeloma is completely understood, but I'm not. Actually, it's a precursor to my lower. Yeah, perfect would be absolutely correct. Answer. BCR Abia. It's a translocation of the long arms of chromosome nine and Kroger's Over 22 that brings on the BCR and A B L genes close together. This causes a hyperactive or terrorist in tiny activity increases, greatly causing the rapid proliferation of this mild last off off the granulocyte basically lineage of cells on causing chronic myeloid leukemia. So this patient presence of multiple which your granulocytes massive splenomegaly on a very fertile blood on the peripheral vision model Mature granulocytes you're thinking chronic myeloid leukemia, chronic myeloid leukemia and straightaway BCR a B l Oh, why that multiple mature granulocyte seen It's because of chronic myeloid leukemia. You got an abnormal proliferation of the journalists. I t a line. You get increased levels are levels of neutrophils base of feels or cetaphil's. Yeah, all of those on. It's due to excessive tyrosine kinase activity, which is about about because of these two genes being ready Close together. So once again in boarding diagram I'm sorry these two white are missing here For some reason, I don't know how that happened. So, basically, progenitor, it's right in America aside, Sterritt recited are red blood cells, the mast cells which are very important hypersensitivity reactions. They released i g e nearly is histamine bottom me not i g the early system mean mile of lasts. They give rise resort cinephiles basic feels neutrophils Monocytes on the motorcycle are in circulation when they go into tissues, they become macrophages. And my car is I'll give rise to platelets. So what happens when there's a proliferation of multiple? Of these? You get chronic myeloid leukemia. You get a high level of our center fails base of fills neutrophils. So basically, these granulocytes, they're much they're greatly increased. Okay, on this can cause hyper risk Casati on something which I'll talk about later, but something that has blast crisis. So if your cells in the blood increase a significant amount, let's say you have white blood cells in the region of 100 times 10 to the park. Three if you have. If you have platelets over 1000. You have so many cells in your in circulation at that time you become hypercoagulable. Very risk us hypercoagulable. You could get strokes on. That's when you need immediate management for these baby. Okay, so once again, always remember acute meaning the upper ones of the mileage progenitor cells talk about acute myeloid leukemia, so I'll just we're going to that slide So acute myeloid leukemia, acute myeloid leukemia, as I showed you in the picture before, is uncontrolled proliferation of the my Lord precursor. So you don't get any differentiate itself, my lord. Precursor cells are the ones which have proliferated. Um, normally, you get an excessive amount of the blast cells, these immature cells. They fill up the board marrow. If these fill up the bone marrow is not enough space for the other cells to the friendship and proliferate. So you get anemic symptoms from a cytopenia Centrums neutropenic symptoms. Chicken got infections for digging. Bal Abruzzi that's typically in the elderly is a serious condition. You need to treat them. It's not like a chronic lymphocytic leukemia. We can just let let me and see how it goes. This one needs treatment immediately. FBC Every single show loads of immature, mild precursor cells in order to lower your cells. Ah, blood for was really sell inclusion room or rods. They clearly looks like a rod into it. Within the cell, it's very easy to spot. Once again, diagnostic would be a bone marrow biopsy management treatment wise. Doing what you want to get too much about this, but depends upon the stage off the tumor off the acute myeloid leukemia. How severe is it? What the other parameter is? Ah, what They're what the Lord of the Condition is on the body, and chemotherapy might be offered to commonly used agents. A site, a Marine and is society. But don't worry about the names. Don't worry about the treatment. Just know it's chemotherapy and this quite intensive chemotherapy. But once again, I need to look into whether the patient is medically fit enough to undergo that's had a toxic therapy. Need to be quite rich, strong, even mentally. To undergo this therapy. I want a line or rods 100% but it's for my student final exams. It can come up. They could give you a picture of it. They can ask it in a question and really see it. Think about acute myeloid leukemia. Okay, correct. While I'm looking me. On the other hand, BCRA BLS have mentioned and tyrosine. Tiny is activity. Increased proliferation, a granulocyte cell line. So you got all those increases. Heart fails. Basic fills neutrophils once again because these cells take up space in the bone marrow could get anemia. Somebody can get nine threats because I have so many white cells they can secrete side of kinds and interleukins causing this night threats splenomegaly. It's one of the causes of the masses. Better regularly and push on the stomach left. We can get only satiety f B c, the blood we would show granulocyte with multiple stages off maturation. We'll see multiple different types of grander side's, much more than normally seen on a blood filled Yeah, go of standard is bored by a biopsy for most of these little logical malignancies, and especially for chronic myeloid leukemia. If you diagnose a patient with this, you'd like to do a cytogenetic analysis as well. See whether they have the BC Arabia mutation, which have further confirm the diagnosis as well as counsel. Future generations treatment. This is one condition or malignancy where you have to do the treatment. Treatment is imatinib. It's an tyrosine kinase inhibitor, and it's commonly Ashton Register and finals. So please, please, please do no imagination. Hydroxyurea once again and, um, its DNA synthesis and can help introduce the proliferation of the cells. But the major treatment it started was in Chinese. Inhibit is on chronic myeloid leukemia. It's a matter of imagination, a quick cheat sheet. This is not in detail. After all, this is essential tips just for your exams. So the night before your exam have a quickly read to the sheet shape. It really help you with All these malignancies have doctor about on an extra one is one which is a PML, so a lot of Children, Children, Children. It's usually in the young. CNN's involvement If you see a child with bruising or a particular rash ruler meningitis If meningitis is out of question, doing FBC within 48 hours and see where this patient has any signs of a level very important to note and very covered. Western Final exams Down Syndrome Children have a higher risk of acute lymphoblastic leukemia. So do you remember that one ML can lead to blast crisis because of older sell Those last week produced You could get stroke like symptoms or any not really or rods. Sorry, this macrolide needs to be removed, and I know why that's there. CML is BCR a B l tyrosine kinase inhibitor to treat with your mature and ran um, asides. Cll Most covered smear cells. Am PM One is the one I haven't talked about, but it causes disseminated intravascular coagulation. So this is because of probiotics sites in AP era the secret tissue factor into the plasma. So the secretion of tissue factor, similar to what happens during our own starting process well trigger the massive activation of various slotting factors using up these clotting factors. So we'll get the prolonged a PTT prolonged PT prolonged bleeding time. Mr. You could bleed through their offices. You may need to rush to give them FFB Carter precipitate depending on the 500 level. But the key thing to know. For example, if there's a patient who has diagnosed a PML, they can have d i. C. Or if you get an animal type picture with D. I see the answer is a PML on myeloma, as I've mentioned crabby, most common is I g always remember I've seen this in clinic If a patient with my lower back is presenting with lower border near which neurological signs basically think about a plasmacytoma so these flowers myself can kind of congregate and stick on it all in the spine, causing spinal cord compression. And this can happen in my lower and do watch out for it. Thank you. Last question. I'll give you 20 more seconds. Stop it there. So perfect the max of the people have gone for the most. You have gone from Cindy, which is the correct answer. People who went for see Don't worry. When I first started letting our hematology in my first exam, I went for see Israel. So once again, this is a common question that should come up finding last creation. But all guidelines quarante locks everything says that it makes logical sense is, well that excisional biopsy is the best way. Get the whole lymph node out and see what's going on to the lymph node. The more tissue you have, better you can see it. Which is Ono? The lymph node is, um and let me let me proliferation. What are the cells in the in the lymph node and gives you a much better, better picture of what exactly is going on? So I had anyone tell me what the diagnosis of this patient is. Any ideas, arch? Cancel, um, for absolutely So this is classic Hodgkin's lymphoma. Asymmetrical inferno. Pretty off the continuous live lymph node regions of cervical going down to the exhilarate. It's contiguous, Asymmetrical. It's not on both sides, and this pain or consumption of alcohol that is classic, classic menstrual. And finally, I don't know how much is your living to practice, But it's classically seen much of a final exam papers, and they have pain on consumption consuming alcohol. Usually the lymphadenopathy is the robbery. So that's another thing which can come up with your questions. A robbery lymphadenopathy. Then again, you're thinking about lymphoma, but in this case is, um, a trick on continuous regions. Hodgkin's Lymphoma? Yeah, the funeral proclamation of the cells off B cell origin, which gives rise to read steam bags cells. This is an important point. Note about the part of physiology of chickens, liver, former Hodgkin's lymphoma. You can only be diagnosed when you have seen read Steinberg's cells. That's it reads 10 bucks out must be present for it to be Hodgkin's lymphoma. And it's basically of B cell origin where the B cells divide divide, and it's thought to be a mutation of the beast. I was cause it to look like the Eagles. Always. I appear and start reach state rex cells, but you have to see these for it to be diagnosed with Hodgkin's them forward, symptomatic of the robbery lymphadenopathy. You could get B symptoms or night sweats, weight loss, fevers and investigations wise was going to do a full blood count. You might not see anything on the full blood count of blood. Film should be normal, but always down on these patients just to rule out whether there was a CLL president before or anything of that sort. Goldman biopsy could be done for some patients when it becomes infiltrates the board market, as for very late stages on Excisional biopsy, is gold standard. Once again, always is excisional biopsy, and one thing you might hear in the wards not very common he tested is ABVD regimen use for Hodgkin's lymphoma. The important to to note from this is BNV. So Beasley of my son and he's been Christine. When Christian cause peripheral neuropathy and these beautiful blow my surgeon cost probably fibrosis. So in this example they could do for you is that they could give you a patient with the classic symptoms of Hodgkin's lymphoma. Mention that they have people therapy for this, and they develop a peripheral neuropathy. What agent was most likely used for chemotherapy and which is most likely caused this this peripheral neuropathy in which case the answer would be vincristine. So we so just know the ABVD regimen roughly. You don't need to know about in depth about how many courses or how many cycles they given anything of that sort. Yeah, this is basically Hodgkin's lymphoma. When a nutshell. Mending reached in back cells must be present. Yeah, not Hodgkin's lymphoma. Once again, I'm control proliferation of being D cells in the lymph node. But this is the new reads in Mexico, so non Hodgkin's willing, there's no really reached in back cells on. It's most commonly B cells, which they're the most common type is actually diffuse B cell lymphoma symptoms. You classically see a little fight an operative, but it's it's symmetrical, symmetrical in front, nobody of noncontiguous lymph node groups. You can go from cervical down to see the inguinal lymph nodes are basic basic part is, it's not cervical than going out to the exhilarate and then moving down. It can skip lymph node regions once again similar to watch kids living former. You could do exist in the biopsies, which is the gold standard on when staging, and both for Hodgkin's are non Hodgkin's. You need to do. A CT scan is well to see for extra normal tissue enrollment, many time the liver can be involved. The stomach could be involved on, in which case, the an ARB. A staging goes higher. So you stayed on Do a CT and treatment for this is our chop. Where are is the rituximab? So the anti CD 20 drug week spoke about quickly. I want to mention about. Hodgkin's lymphoma is the most common type. Is Nodular sclerosing Hodgkin's lymphoma, the one with the West. Prognosis on the one which has the best prognosis is lymphocyte predominant Hodgkin's lymphoma. Don't worry about joining it down. It's not very common and medical through final examinations, but I'll just repeated once work. There's a rare question on it. I highly, highly doubt it's more the next step to know this. But for anyone, if you do want to take another fit, you can. Most common type is not dilated sclerosing. Hodgkin's lymphoma, the one with the best prognosis is lymphocyte predominant on the one with the West. Prognosis is live beside deplete, but once again you don't want to take no definite. Don't worry, it's not very essential for your medicine and final exams. So on our of our strange thing I've done it. Very simple is a very simplified version and our best aging. It can get much, much, much more complicated. But just to give you a break, broad idea of what it is you have stage someone a stage one when they only have one live north region and rob to when they do live in the world, but both on the same side of the diaphragm a the boat below or both above. Usually it's both above. Stage three is where the liver nutrition that both sides the diaphragm are involved. And Stage four is when these diffuse involvement of Extranodal issue a key thing to note years for Stage four, usually organs, which are away from lifting, ordering Jin's need to be involved. So it got me a live regions involved on the neighboring organ. It will. It's usually a lymph related, So if I could live another in world on the liver has growths on, it is well, that's where you know it's stage four because it's moved to an extra little site which is distant from the hospital location. Okay, and then you go one a one b. So one is the absence of these, um, one B is the presence of the symptoms to waste. Absence of the symptoms to be it's presence of the symptoms on the presence of the symptoms. In the kids' worst prognosis, Absence of recent times indicates a better prognosis. Once again, I talk about to realize is earlier well repeated here, very government live for more patients undergoing chemotherapy. Patients at high risk should be given IV allopurinol or IV respiratory. It's don't give both together, And I think that's the end of my presentation. Leave without the feedback form. Sorry for the delay today and starting Sorry for the slight mishap which happened. Thank you so much for joining. And I hope it is useful. Yeah, guys, let me as well apologize for the delay. We managed to, uh, expand our capacity, and I think the transition is quite was quite challenging. So we appreciate it runs patients, and we hope they didn't disrupt your session. Too much is washing their know what? I was fine. Okay. So, uh, we hope you guys found the metal event page useful as well. Please do. Let us know how you guys found it as well. On diffuse. Have any more questions you free to ask you Please be back how you felt about the metal platform and let us know how we can improve it. It's something we're gonna be increasingly using for our sessions. Yeah, so just about be symptoms someone else be symptoms of fever, weight loss and night sweats on. The last sentence I mentioned is for tumor lysis prophylaxis. You give IV allopurinal or IV respiratory is don't give both together because then they won't work. Well, you can't give Raspberry case and I v l a p r n no. They don't work well together to give either or Yeah, you don't explain the bees in case Intention Day. Thank you, Polly, for the nice comment. Look, this fringe A This is a very interesting question. Main difference between you Give me a and lymphoma. So there is basically in lymphoma. Most of the periphery of cells are held within the lymph node and in leukemia there, in circulation or in the bone marrow. But if you want to go into the depths of hematology on understanding immunology, the whole new level there isn't intermixing face with someone for myself. Mean circulation. Some you keep yourself might be in the lymph node. But if I was at the at the master level, don't complicated all that. Just think of it. The lymphoma. It's a solid organ to run almost. It's within the liver nodes, the perforating cells. You keep me as it's in the circulation border matter and say, Look, you're Asian. That's the best way to think of it. Yeah, And in terms of a dull just sometimes it's quite difficult because we go through a period of being process for our slides. So sometimes the slides aren't available until immediately, just before the sessions. Sometimes quite difficult for us to upload. But we will try to keep them in mind. And thank you for bringing that to our attention. Absolutely, Doctor. Today, even two minutes advance. Okay, So, Jesse, if you, uh, give us a message on a messenger, um, want someone for my team? Will, will that be more than happy to give access to some of the sessions? It's difficult to give access to all of them, but the latest ones for sure? Yeah, just on the special about slide. It's a bit hard for us to provide slides before sessions just goes on a logistical level. It's hard to disseminate. This slides you produce to everyone s. So it's just easier for us as fortunate off the recession to guess, get disseminated form, which people will fill out. And then they just access the slides and recording on that form because it's difficult to know is gonna tend and be able to fill it today, access to slightly recording. I think we, since we are putting the recording you can go through it at your own pace, is we're later on just to consolidate your learning. So we do provide that in. Ah, generally, it's lost about steroid use in, um, in new chemo and lymphomas. What they do is start can just suppress the production of these cells. And when you're doing a diagnostic testing given to start our just before, you may not be able to figure out what exactly is going on. What you came in today is the what lymphoma. It is kind of like hamburger diagnostic capability usually stop the steroids if their own chronic. For him, well, let's see patients have frequent exacerbations of COPD, and I've just been on a, uh, does the steroids and they're presenting with the symptoms. You don't want to do the investigation straight away, you know, wait for a period after the steroids through the investigations. Don't worry too much about it. It won't really come up and rest your father something more to keep in mind off. I know. I think a point is taking and we can really understand. And we'll try our best from our side logistically to try. And what's the role of the fluids and hypocalcemia? So for mild, moderate hypercalcemic fluids is usually sufficient. It treated for more severe head because, you know, if someone has happened casting of malignancy, you use things like a response minutes. Okay. IV bisphosphonate. Did you see the mainstay to manage us to be a senior? Absolutely. In just in the acute scenario, when you've seen the patient coming in a typical senior give IV fluids rest the bisphosphonate take 2 to 3 days, sometimes even four days to it. So I haven't really should be the baseline. What? Carry try. It is basically abdominal right. Upper abdominal pain. Um ascites and hepatomegaly so tender. Hepatomegaly in, uh, ascites if you think about but carry ignitions lives explained what carry quite well. Oh, so there's a question before general question. How do you What's the best way to study for SPH uh, Crestor to tell you for everything. All of us will agree that question Banks are quite good. I didn't quite finish is a very regardless it for and I completely agree with them is the fact you need to know your basics. Well, it's well, there's no point knowing loads of guidelines without it's happening. The basics just for every condition understand basically what's going on. You don't need to know every specialist level, you know, one of the receptors of the molecules and everything would just basically what the pathophysiology is, so you can always work up from there and loads of quite but practice questions really important. I'm just right on the Washington said You're more likely to remember or recall the next time you go there something I found out. I think nation should have found that probably is what? Yeah, I think if you're using question about all the time, there's a risk you might fall into just when you're coaching, examine security, just relying on pattern recognition, you just relying on what that question bank, SBA said. You're trying to remember the different sort of high yields chemical pills that that question, Bank SP said. And you kind of apply that to the finals question. So obviously, the question is a useful, but you need to know your principles. Okay, you starting to be a doctor as well as examples? Well, so you need to be solid good principles, and you saw it on principle is in for SPS, which are not too sure about are your They require you to think of a couple of different levels. If you're solid on your basic clinical principles, you'll be you should be a conference on system. Get submission any more questions, or I couldn't remove it when it's just said it's a very important point of 20 people miss out on, you know, studying for exams, starting to be a doctor and not a great recognition, definitely a trap. A lot of medical students fall into the absolutely be aware of that. The way to go around it is to try and think what I least I don't know what it helps other people, but it helps me is I try to think, Why is that the pattern? And that kind of makes me think about. Okay, So this is the patent. Probably because this is this is this is what the part of physiology is to try to decode the pattern. And in that way, herb you, rather than just trying to know the bad in, it's constantly just asking why? Why? Why? For anything you're learning your quantity, asking why your question it learn about continuously questioning an advantage to learning. Okay, You know, if you doing question banks all the times keep question you're learning and keep broadening your knowledge base. Okay? Thank you, guys for junior and me, Pretty pre. She all you guys can turn it up, but, uh, you know, it's ah, late night time job for most guys. But we appreciate you guys coming in and watching our lectures. Honestly, we wouldn't be able to do any of this without all of your support and very appreciative. And I'm very grateful to provide a service to you guys as well. And we have a free clinic. Is e session tomorrow If you guys are interested in brushing up on some of your basics, um, of them that finals easy. Session return next Tuesday. So same time. And we will not. We're not anticipating to have the same problem, so it will be much longer. Please let us know how middle transition this started. Limit on transition. There's no tomorrow is I know you know. Session. Yeah, it's a It's a Monday. There. I see where we schedule a section on Friday night. Are you sure it's okay? I'm just taking the Mondays we're doing. Ah, it's 11. The A My bed parties Ever. Uh, well, I know someone asked if we can post sort of weak calendar that will post it on a social media on the weekend, just er events for the week. So I haven't really been What's happening each day are yesterday. I think tomorrow was in his communication are recession is on one day and all our length and everything are up on our Facebook page. Please. Do you like our Facebook? And our social could be a bit everything there. Mental links, zoom links. Everything will be on that. So and any questions, Any doubts you have just message or Facebook page, there's someone always manning it. If you have questions about any typical stuff, message our community. Please show your questions that everyone can see your pressure and we'll be happy to answer it as well. And if you we don't know the answer, we'll direct you to someone who would be. How's my expertise? Down to the question is, well, tumor lysis syndrome. So basically, it's what the name says. You're giving chemotherapy to ablation the tumor of best releasing all its contents in. So you got the your your app. You read the, uh, potassium levels, the phosphate levels. So you got hyperkalemic a hyper course redeeming a hyper you receive? Yeah, high phosphate levels binds to the calcium, dropping the calcium down in the serum. Onda, as I think, initial to mention in the chats. The reason why the phosphate remains high despite that is because the cells are constantly breasting. So they're releasing phosphate more and more into the serum. You get this hyperkalemic hypophosphatemia hyperuricemia but hypocalcemia I hope that I'm just a question lazy you're moving. Does the numbers on metal just stay with like, whatever the attendance is there just the numbers, and actually, I think they dropped. So I think some of the master there, I'm going to get in my dog. I mean, it's still currently over 100 people of medals. We had over 100. Yes, sir. Because of the let's restriction kind of person resection one's only thing be dried. Yeah. Oh, what happened with the Internet? I think we had a rife. I problem on, but we are. Most of us are in the same combination. So we all had a widespread there. Uh, problem. Okay, but waiting room. All right. You stop the recording. Uh oh. Yeah, yeah, yeah. Uh